Doctor Intake Form
MedSpa
Customer Details:
Full Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prefix
First Name
Last Name
MedSpa Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
LinkedIn
Facebook
Instagram
TikTok
Internet
Other
Please Specify
Website (If Applicable)
Years In Practice
Less Than 1 Year
1-3 Years
4-10 Years
10+ Years
What Treatment Services Do You Offer
Botox And Derma Fillers
Laser Hair Removal
Skin Rejuvenation (Microneedling, PRP, etc.)
Chemical Peels & Facials
Body Contouring (Coolsculpting, Emsculpt, etc.)
IV Therapy & Wellness Treatments
Hormone Therapy (HRT,TRT)
Medical-Grade Skincare Treatments
Other
Do You Currently Have A Team?
Solo Practitioner
Small Team (1-3 staff)
Medium Team (4-10 staff)
Large Team (11+ staff)
What Are Your Top 3 Goals For The Next 6 Months?
What Are The Biggest Challenges Preventing You From Achieving These Goals?
Not Enough New Patients
Low Patient Retention/Repeat Bookings
Weak Online Prescence Or Low Website Traffic
Ineffective Social Media Marketing
Poor Lead Follow-Up System
Other
Do You Currently Use Social Media For Your Practice? (Check All That Apply)
Instagram
Facebook
TikTok
YouTube
LinkedIn
I Don't Use Social Media
How Often Do You Post On Social Media
Daily
2-3 Times A Week
Once A Week
Rarely/Never
Do You Currently Run Paid Social Media Ads?
Yes, Actively Running Ads
I've Tried But Didn't See Results
No, But I'm Interested
No, I Prefer Organic Marketing
How Do You Currently Generate New Clients? (Check All That Apply)
Word-Of-Mouth Referrals
Google Search & Website Traffic
Social Media & Online Ads
Local Community Events Or Networking
Partnerships With Other Businesses (Gyms, Salons, Wellness Centers)
What Type Of Marketing Do You Need?
Website Optimization & SEO Improvement
Social Media Management & Content Creation
Instagram & Facebook Advertising
Google Ads & Local SEO Strategy
Lead Generation & Patient Conversion Strategies
Email Marketing & Client Retention Strategies
What Is Your Estimated Marketing Budget Per Month
Under $500
$500-$1,500
$1,500-$3,000
$3,000+
Are You Open To Creating Videos Or Sharing Photos For Marketing Purposes?
Yes, I Can Provide Videos/Photos
I Need Help Creating Content
I Prefer Text-Based Content Only
Do You Have A System In Place To Follow Up With Potential Clients?
Yes, We Follow Up Via Phone, Email or Text
No, I Need A Better Follow-Up System
I'm Not Sure
How Will You Define Success In This Partnership? (Check All That Apply)
More New Client Appointments
Higher Client Retention & Repeat Bookings
Increased Online Engagement & Brand Awareness
Higher Revenue & Profitability
Improved Website & Ad Performance
How Soon Are You Looking To Get Started?
Immediately
In The Next 30 Days
In The Next 3-6 Months
Is There Anything Else We Should Know About Your Practice And Goals?
Submit
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